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ALERT Child Questionnaire
Jane Rekas, LCSW / Western Psychological & Counseling Services
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Over the past week, how often had the child?
destroyed property
never
sometimes
often
Clear selection
been unhappy
never
sometimes
often
Clear selection
behavior caused school problems
never
sometimes
often
not applicable N/A
Clear selection
had temper tantrums
never
sometimes
often
Clear selection
worrying prevented doing things
never
sometimes
often
Clear selection
felt worthless or inferior
never
sometimes
often
Clear selection
had trouble sleeping
never
sometimes
often
Clear selection
changed moods quickly
never
sometimes
often
Clear selection
used alcohol
never
sometimes
often
Clear selection
was restless, trouble staying seated
never
sometimes
often
Clear selection
engaged in repetitious behavior
never
sometimes
often
Clear selection
used drugs
never
sometimes
often
Clear selection
worried about almost anything
never
sometimes
often
Clear selection
needed constant attention
never
sometimes
often
Clear selection
Child's first name
Your answer
Your email
Your answer
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